failure to thrive

1. Presented by-Dr Rajeev
An Approach To Failure To
Thrive

2. SLO
 Definition
 Epidemiology
 Types
 Classification
 Clinical manifestations
 Etiology
 Approach
 Treatment
 Prognosis

3. Definition
 Weight for age less than 5th percentile
 Length for age less than 5th percentile
 Weight velocity less than 5th percentile
 Body mass index less than 5th percentile for age
and gender
 Weight less than 75% of median weight for age
 Weight less than 75% of median weight for length
 Weight less than 5th percentile for age on two
occasions or weight deceleration crosses two
major percentile lines over time (centile lines used:
5, 10, 25, 50, 75, 90, 95)

4. When should suspect FTT ?
 Height/length for age <-2 Z score on standard
growth chart
 Rate of growth < 5 cm/yr
 Crossing of two major percentile line e.g.,
declining from above 75th percentile to below
50th percentile on height over a period of time
 Child is growing much below the mid parental
height range

6. Average rate of height gain at different
ages
Age Height/Length
1st yr 25 cm
2nd yr 12.5 cm
3rd yr 7.5-10 cm
3-12yrs 5-7 cm
Adolescent girls-12-16
yrs
Adolescent boys 14-18
8 cm/yr
10 cm/yr

7. Average rate of wt gain at different
ages
Age Expected daily wt gain
(gm/day)
0-3 months 30
3-6 months 25
6- 9 months 15
9-12 month 10
1-9 yrs 2-2.5 kg/yr
10-18 yrs 4-6 kg/yr

8.  Weight get affected earlier and to a greater
extent as compared to linear growth or growth of
head circumference which get affected in severe
and prolonged nutritional deprivation
 As weight is accepted as simplest and most
reasonable marker of FTT, the condition has
been now renamed as weight faltering
Which is most reasonable marker of
FTT ?

9. Epidemiology
 Nearly 80% of children with FTT present in the first
18 month of life
 In India as per national family health survey-3
(NFHS-3, 2005-2006) using WHO growth
standard, 22.9% children under 3 yrs are wasted
with higher prevalence in rural 24.1% as
compared to urban areas

10. Types
 Organic FTT (30%) –Caused by a known medical
condition (Biological FTT )
 Nonorganic( 70%)-Caused by psychosocial
neglect, poverty and accidental errors in feeding
(Environmental FTT)
 Mixed type- organic + non organic
 FTT and malnutrition are closely related.
 FTT is medical problem or a label of investigation,
whereas PEM is a diagnosis.

11. Severity classification of FTT
Method Mild
FTT
Moderate
FTT
Severe
FTT
Gomez classification
(Present wt/median wt for age)
75-
90%
61-75% <60%
Wellcome classification
Height/median height for age
Weight/median weight for age
90-
94%
80-
89%
85-89%
70-80%
<85%
<70%
McLaren classification
(Present weight
:height)/(median wt: height for
age)
81-
90%
70-80% <70%
Classification based on 90- 85-89% <85%

12. CLINICAL
MANIFESTATIONS
 Clinical manifestation of FTT depends on
-Age of onset
-Associated symptoms
-Severity of malnutrition
-Degree of impairment of growth parameters

13.  Inadequate weight for corrected age, weight for
height and BMI, as well as failure to gain adequate
weight over a period of time
 Growth parameters should be measured serially
and plotted on growth charts appropriate for the
child’s sex, age.
 In preterm LBW babies corrected age can be used
to compare physical growth and development till 2
yrs of age
CLINICAL MANIFESTATIONS

14.  Nutritional deficiency –Poor wt velocity
slow deceleration of height velocity poor
head growth as compared to children with normal
variant
 Systemic illness- FTT manifests as early as 8 wks
of age depending on age of onset of illness and
have more severe wt deficit as compared to the
children with behavioral difficulties leading to poor
feeding
CLINICAL MANIFESTATIONS

15.  Underlying illness- Respiratory distress, cyanosis,
recurrent diarrhea, vomiting, jaundice and food
allergy.
 Organic disease- Dysmorphic facies, cleft lip,
cleft palate, cyanosis, respiratory distress,
cardiac murmur, developmental delay, tone
abnormality
 Subtle presentation- food allergy, chronic renal
insufficiency, celiac disease
CLINICAL MANIFESTATIONS

16.  Rumination, anorexia nervosa, bulimia may be
noted in few
 Neglect of hygiene diaper rash, dirty
fingers and nails, intertrigo, dirty skin and dress
etc.
 Alopecia on occiput baby was lying
unattended for prolonged period
 Tear in the frenulum and angle of mouth
force feeding by a rejecting mother
 The child may lack eye contact and fails to interact
with mother and environment
 Physical abuse psychosocial FTT
CLINICAL MANIFESTATIONS

17.  INADEQUATE INTAKE
 MALABSORPTION
 INCREASED METABOLIC DEMAND
Diagnostic Classification of Causes
and Selected Examples of FTT

19. INADEQUATE INTAKE
Inadequate food offered
-Food insecurity
-Poor knowledge of child’s needs
-Formula dilution or excessive juice
-Breastfeeding difficulties
-Medical child abuse/caregiver fabricated illness
-Medical neglect
-Food fads including “rice” milk as substitute for
formula or cow milk
Diagnostic classification of causes
and selected examples of FTT

20. Child not taking enough food
-Oromotor dysfunction, neurologic disease
-Developmental delay
-Behavioral feeding problem (altered oromotor
sensitivity, pain and conditioned aversion)
-Anorexia from systemic causes
Diagnostic Classification of
Causes and Selected Examples of
Failure to Thrive

21. Emesis
-Pyloric stenosis
-Gastroesophageal reflux
-Eosinophilic esophagitis
-Vascular rings
-Malrotation with intermittent volvulus
-Increased intracranial pressure and other
neurologic disorders
-Inborn errors of metabolism
-Rumination
-Cyclic vomiting
Diagnostic Classification of
Causes and Selected Examples of
Failure to Thrive

22. MALABSORPTION
-Cystic fibrosis
-Celiac disease
-Hepatobiliary disease
-Food protein allergy, insensitivity, or intolerance
-Infection (giardiasis)
-Short gut syndrome
Diagnostic Classification of
Causes and Selected Examples of
Failure to Thrive

23. INCREASED METABOLIC DEMAND
-Insulin resistance (intrauterine growth restriction)
-Congenital infections (HIV, TORCHES)
-Syndromes (Russell-Silver, Turner, Down)
-Malignancy
-Chronic disease (cardiac, pulmonary, renal)
-Metabolic disorders
-Immunodeficiency/auto inflammatory disorders
-Endocrine (diabetes mellitus, diabetes insipidus,
hyperthyroidism)
Diagnostic Classification of Causes
and Selected Examples of FTT

24. NEUROLOGIC
 Cerebral palsy
 Hypothalamic and other central nervous system
tumors (diencephalic syndrome)
 Neuromuscular disorders
 Neurodegenerative disorders
RENAL
 Recurrent urinary tract infection
 Renal tubular acidosis
 Renal failure
Failure to Thrive: Differential Diagnosis by
System

25. GENETIC/METABOLIC/CONGENITAL
 Sickle cell disease
 Inborn errors of metabolism (organic acidosis,
hyperammonemia,
 Storage disease)
 Fetal alcohol syndrome
 Skeletal dysplasias
 Chromosomal disorders
 Multiple congenital anomaly syndromes (VATER,
CHARGE)
Failure to Thrive: Differential Diagnosis by
System

26. CARDIAC
 Cyanotic heart lesions
 Congestive heart failure
 Vascular rings
PULMONARY/RESPIRATORY
 Severe asthma
 Cystic fibrosis; bronchiectasis
 Chronic respiratory failure
 Bronchopulmonary dysplasia
 Adenoid/tonsillar hypertrophy
 Obstructive sleep apnea
Failure to Thrive: Differential Diagnosis by
System

27. MISCELLANEOUS
 Collagen-vascular disease
 Malignancy
 Primary immunodeficiency
 Transplantation
FTT : Differential Diagnosis by
System

28. Algorithm for the evaluation of
FTT

31. Clinical evaluation of FTT
 HISTORY
 CLINICAL EXAMINATION

32. HISTORY INTERPRETATION
DIET
Diet assessment Quantification of total calorie
intake
Technique of milk/formulae
preparation
Over diluted milk- low
calorie content
Over concentrated milk-
unpalatable
Type of food-Fruit juice,
soda, aerated drinks, water,
inadequate or inappropriate
complementary foods
Poor calorie intake
Clinical evaluation of FTT-
HISTORY

33. HISTORY INTERPRETATION
Feeding behavior
Observed feeding session Helps to understand
behaviors like easy
distractibility, feeding battles,
swallowing dysfunction.
Proper supervision and
parent child interaction
required
Technique of feeding Improper feeding
Intermittent snacks Poor meal time, early satiety
Clinical evaluation of FTT-
HISTORY

34. Clinical evaluation of FTT-
HISTORY
MEDICAL HISTORY INTERPRETATION
Birth history- prematurity,
IUGR, complications at birth
Catch up growth may be
incomplete in many babies
History of recurrent illness-
otitis media, diarrhea,
pneumonia
Inadequate catch- up growth
opportunity in between illness
Contact with tuberculosis,
HIV, recurrent infections
TB, HIV, other
immunodeficiencies
Stool pattern, worms in stool Malabsorption syndrome

35. Clinical evaluation of FTT-
HISTORY
MEDICAL HISTORY INTERPRETATION
Polyuria, polydypsia, FTT despite
increased appetite
RTA, Diabetes mellitus,
diabetes insipidus,
hyperthyroidism
Vomiting and reflux GERD
Past medical history- chronic
anemia, asthma, renal disease,
cardiac disease, liver disease
Pointers towards the
organic cause for FTT
Injury marks, frequent accidents Neglect, abuse

36. Clinical evaluation of FTT-
HISTORY
MEDICAL HISTORY INTERPRETATION
Family history- parental
height , parity, sibling
height
Shorter parental height and high
parity has been shown to have
slow weight gain in infancy
Any illness in family Developmental delay,
constitutional delay
Discord/ stressors in
family
Child neglect

37. CLINICAL EXAMINATION INTERPRETATION
Anthropometry- accurate measure wt
, ht/length, head circumference and
plot on reference growth chart
Severity of FTT
Recurrent, diarrhea, anemia, poor
growth, poor appetite
Celiac disease
Steatorrhea, chronic respiratory sign,
bronchiectasis, salt wasting crisis,
increased sweat chloride
Cystic fibrosis
Clinical evaluation of FTT-clinical
Exam

38. CLINICAL EXAMINATION INTERPRETATION
Icterus, hepatosplenomegaly,
bleeding, pallor, ascites
Chronic liver disease
Breathlessness with or without
cyanosis, murmur
Congenital heart disease
Recurrent abdominal pain,
bloody diarrhea
Milk protein allergy,
inflammatory bowel disease
Organ specific sign-
neurological, immunological,
renal
Organ specific illnesses
Clinical evaluation of FTT-clinical
Exam

39. Tests Interpretation
Complete blood count Anemia, infection
Urine analysis Urinary tract infection
Stool for ova ,cysts, fat
globules,
Parasitic infestation, fat
malabsorption
Total protein and albumin Hypoproteinemia
LFT-AST, ALT, PT, PTT, aPTT Chronic liver disease
Tests for tuberculosis and
congenital infections
TB, TORCH infections
Retro test HIV
RFT- serum creatinine CKD
Serum electrolytes, VBG RTA
Celiac screen Celiac disease
Laboratory studies

40. Tests Interpretation
Sweat chloride test Cystic fibrosis
Skeletal survey Look for evidence of physical
abuse, dysmorphic
syndromes
Bone age To differentiate genetic cause
from nutritional causes
BA=CA (genetic)
BA<CA (nutritional)
Thyroid function tests Hypothyroidism/Hyperthyroidi
sm
Tests for tuberculosis and
congenital infections
TB, TORCH infections
Metabolic screen IEM
Allergy testing Specific food allergy
Laboratory studies

41. TREATMENT
Goal of treatment -
Improving nutritional status through provision of
adequate nutrition
Treating the underlying cause of FTT if present
Improving the caregiver’s ability to provide
adequate diet to the child through education,
capability enhancement and psychological
support
Preventing a relapse of FTT through close follow
up and monitoring

42. TREATMENT
Mild FTT
 Increase in nutrient intake can be achieved by
making appropriate changes in diet content,
feeding schedule and feeding environment.
 Continuing to provide home-based food with
correction of faulty feeding practices and suitable
modifications to improve calorie content
 Feeding environment with minimal distractions
helps in achieving better intake of food and less
of food battles
 No need of special diet or drug in mild FTT
 Regular monitoring for catch-up growth is

43. TREATMENT
Moderate FTT
 Multidisciplinary team comprising of pediatrician,
dietician, child psychologist, developmental
specialist, social worker and a nurse
 Outpatient management needs- frequent follow
up and home visits
 Diet modified to produce calorie dense food
 Treatment of any underlying medical illness
 Improving psychosocial problem
 Changing feeding environment
 Changing feeding routine

44. Indications for hospitalization-
 Severe FTT
 Failure of outpatient management(no response
after 23 months of outpatient management) a
specialized, multidisciplinary inpatient assessment
should be considered.
 Underlying medical problem requiring in-hospital
care
 Psychosocial circumstances that put the child at
risk for harm
TREATMENT

45. Feeding pattern
Constant feeding schedule as per the age
Need to feed 8-12 times/day in the first 4 months
as compared to 6-8 feeds/day in later infancy
Allow the infant to feed for 20-30 min
Offer solids before liquid
Avoid distraction during feeding
>1 yr age children follow rule of 3----3 meal,3
snack,3 choices
Avoid grazing diet pattern and snacks should be
timed at least one hour before meal time
TREATMENT

46. Feeding environment- comfortable, relaxed with
minimum distraction
Eating with other family members should be
encouraged
Avoid force feeding, strict parenting approach,
autonomy struggle as it leads to food battle and
creates unpleasantness
Regular interaction between physician, dietician,
nurse practitioner and psychologist is essential
TREATMENT

47. Calorie requirement-
Calorie and vitamin rich food required for catch-
up growth
Calorie intake should be 150 % of
recommended daily calorie intake based on the
expected wt not the actual wt
 Can be achieved by gradually increasing food
intake or by enrichment of food to increase
calorie content
TREATMENT

48.  High calorie formulas that offers more than 20
Cal/ounce (1 ounce=28.3 gm) and high calorie
supplements like oil are useful
 High energy milk like F100- 100 Cal/100 ml (milk
100 ml, sugar 1 tsf, oil ½ tsf), cereal milk and
thickened feeds (milk 100 ml+2 tsf cereal flour or
SAT mix) are beneficial.
 SAT mix is precooked ready to mix powdered
cereal pulse mixture prepared from rice: wheat:
black gram: sugar in the ratio of 1:
TREATMENT

49.  Family counseling is important
 Weight gain in response to feeding establishes
psychological FTT
 A wt gain of ½ kg/wk or 70 gm/kg/wk is expected
 Children with severe malnutrition- incremental
increase in calories to avoid refeeding syndrome
 Refeeding syndrome-A syndrome consisting of
metabolic disturbances that occur as a result of
reinstitution of nutrition to patients who
are starved or severely malnourished.
TREATMENT

50.  The type of caloric supplementation is based on
the severity of FTT and the underlying medical
condition.
 The response to feeding depends on the specific
diagnosis, medical treatment, and severity of FTT.
 Minimal catchup growth should generally be 23
times the average weight gain for corrected age.
TREATMENT

51.  Multivitamin supplementation should be given to
all children with FTT to meet the RDA, because
these children commonly have iron, zinc, and
vitamin D deficiencies, as well as increased
micronutrient demands with catchup growth
 Underlying medical condition-organic causes of
FTT should be treated appropriately
TREATMENT

52.  Fat malabsorption, cystic fibrosis and other
condition with pancreatic insufficiency –
pancreatic enzyme replacement therapy
 Celiac disease- gluten free diet
 Food allergy- Avoid specific food allergen
 CHD, CLD, CKD, RTA, endocrine disorder-
specific treatment should be provided
 Immunization to be as per schedule.
 Intercurrent illness to be treated promptly
TREATMENT

53. Therapy for the psychosocial factors should be
specific for the
underlying issue (maternal depression, insufficient
funds for food)
Parent education should focus on what is normal
infant development and correcting any parental
misconceptions about feeding and temperament,
as well as learning the infant cues for hunger,
satiety, and sleep.
TREATMENT

54. Some children who develop feeding aversion
behaviors will require treatment by a specialized
feeding team.
If abuse or purposeful neglect is a concern, the
family should be referred to the child protective
service team.
TREATMENT

55. PROGNOSIS
 FTT early in life, regardless of cause, is concerning
because maximal postnatal brain growth occurs in
the first 6 mo of life.
 Studies investigating the longterm sequelae of FTT
in young infants and children have been conflicting,
and there is no clear consensus regarding the long-
term emotional, cognitive and metabolic effects.
 Despite inconclusive longterm outcomes in children
who have FTT, investigators support early
nutritional interventions for children who have poor

56. Early FTT may be associated with increased risk
factors
(including dyslipidemia, hypertension, and glucose
intolerance) for cardiovascular disease as an adult
perhaps relating to epigenetic responses to
impaired nutrition and/or inflammation.
The growing importance of cardiovascular disease
among adults in lower and middle income nations
where many children still have inadequate nutrition
offers yet another reason why early FTT should be
cause for concern globally.
PROGNOSIS

57. References
 NELSON’S TEXTBOOK OF PEDIATRICS ,20th EDITION
 KE Elizabeth –Nutrition and child development , 5 th edition
 Failure to Thrive: An Update SARAH Z. COLE, DO, Mercy
Family Medicine Residency, St. John’s Mercy Medical
Center, St. Louis, Missouri, American Academy of Family
Physicians. April 1, 2011 , Volume 83, Number 7:829-834
 Effect of community based management in failure-to-
thrive: randomised controlled trial. Wright CM, Callum J,
Birks E, Jarvis S ,BMJ. 1998;317:571-574
 PG textbook of pediatrics- Piyush Gupta, 1st edition
 OP Ghai- textbook of pediatrics- 8th edition
 Failure To Thrive: An Old Nemesis in the New Millennium
 Textbook of pediatric gastroenterology by Riaz 2011

58. THANKS